Health and Domestic Violence - Good Practice Guidelines

Principles of Good Practice for working with women experiencingdomestic violence

Guidance for mental health professionals

What is domestic violence?

Domestic violence is physical, psychological, sexual or financial abuse that takes place within an intimate or family-type relationship and forms a pattern of coercive and controlling behaviour. Crime statistics and research both show that domestic violence is gender specific - usually the perpetrator of a pattern of repeated assaults is a man. Women experience the most serious physical and repeated assaults.(i)

Any woman can experience domestic violence regardless of race, ethnic or religious group, class, sexuality, disability or lifestyle. It is estimated that one in four women will experience domestic violence at some time in their lives.

In this document, we will refer to survivors of abuse as female and perpetrators as male.

Aims of the Good Practice Guidelines:

To increase safety for those experiencing domestic violence

To raise standards for users of mental health services

To raise awareness of domestic violence among mental health professionals

To increase safe choices for women and children experiencing domestic violence where mental health is also an issue

To encourage liaison between domestic violence and mental health sectors

Some information about mental health and domestic violence

Many - perhaps most - women and children living with or escaping domestic violence will experience some mental health issues, including depression, anxiety, eating disorders, self-harming behaviour, post traumatic stress disorder (PTSD), bipolar disorder (also sometimes referred to as manic depression), or schizophrenia. These might result from the abuse, or predate it; experience of abuse can also exacerbate an existing condition. Sometimes these problems are very severe, and require intervention from mental health professionals.

Mental health professionals tend to underestimate the proportion of their clients who experience domestic violence and to have only limited contact with domestic violence services.(ii)

Between 50% and 60% of women mental health service users have experienced domestic violence, and up to 20% will be experiencing current abuse(iii)

Domestic violence and other abuse is the most prevalent cause of depression and other mental health difficulties in women(iv)

Between 35% and 73% of abused women experience depression or anxiety disorders; this is at least three times greater than the general population (v)

Domestic violence commonly results in self-harm and attempted suicide: one-third of women attending emergency departments for self-harm were domestic violence survivors; abused women are five times more likely to attempt suicide; and one third of all female suicide attempts can be attributed to current or past experience of domestic violence(vi)

The figures for black and ethnic minority women are even higher: for example, 50% of women of Asian origin who have attempted suicide or self-harm are domestic violence survivors (vii)

70% women psychiatric in-patients and 80% of those in secure settings have histories of physical or sexual abuse(viii)

Children who live with domestic violence are at increased risk of behavioural problems and emotional trauma, and mental health difficulties in adult life(ix)

Being diagnosed with a mental health problem leads to negative stereotyping, stigmatisation, and discrimination, and can result in social isolation and exclusion(x). Women experiencing domestic violence already suffer from stigmatisation and social isolation, and are particularly vulnerable to the additional negative effects of being labelled as "mentally ill". They may find it even harder than other women to report or even to name their experience as domestic violence. When they do seek help, their credibility may be questioned(1) and they may be unable to access any suitable sources of support. It is therefore crucial that women are always believed when they disclose abuse.

Any response must ensure that the safety of women and children is the first priority.

Do not blame women for the abuse they experience from their partners or other family members. Responsibility(2) for the abuse lies with the perpetrators.

Always believe women who disclose abuse. The perpetrator may have told her that no-one would believe her - your belief in her story is vital.(3)

All mental health organisations need to develop specific domestic violence policies, together with appropriate protocols and guidelines for responding to clients who have experienced domestic violence.(4)

We recommend that all mental health organisations appoint a member of staff with designated responsibility for domestic violence issues (5), in order to promote and implement these policies and guidelines, and to work in partnership with local domestic violence organisations to take this agenda forward.

All those working in mental health services should be given regular training on domestic violence awareness issues. Your local Women's Aid organisation or Domestic Violence Forum should be able to help with accessing appropriate training.

Ensure that your service is accessible to women of all races, ethnicities, cultures, ages, sexualities and abilities. Culturally appropriate services should be developed for those from minority ethnic groups, in consultation with representatives from these groups. Accredited interpreters should be available to call on when necessary: the use of partners or other relatives is inappropriate and may prevent disclosure of abuse.

Organisations should work towards introducing routine questioning of all clients about domestic violence (experienced or perpetrated) at the time of assessment, provided that this can be done safely, and never in the presence of a partner or other family member . Such questioning should not, however, be introduced without appropriate training so that staff feel confident and able to respond appropriately to disclosures of abuse.

When domestic violence is disclosed, it should be documented carefully. Evidence can be important when the perpetrator has been charged with an assault, in helping an abused woman obtain protection through the civil courts, or - when a woman is subject to immigration restrictions - in assisting with an application for leave to remain in the UK under Part 8 (Domestic Violence) of the Immigration Rules.

Safety planning must be treated as a priority, whenever a client discloses abuse.

Risk assessments should include consideration of the risk to the client from others, including partners, former partners, family members, and others within the household. There should also be an assessment of the risks to other vulnerable people within the household - e.g. children, or older people. Assessments should include the risks involved when domestic violence and mental health issues, such as self-harming behaviour, are both present.

When a service user is identified as a perpetrator of domestic violence, the safety of those experiencing the abuse must be treated as a priority. In such circumstances, mental health professionals should ensure that the partner receives support and information about options and services, provided this can be done safely.(6)

Women living with domestic violence will not necessarily want to end their relationships, or may decide to return to an abusive partner. They should be offered a choice of options, time to talk these through and non-judgmental support in making their own choices.

All staff working in mental health services need to be aware of local and national domestic violence services, and how they can be contacted when needed, and should ensure that this information is easily available to women service users(7). In most areas, specialist refuge provision for women with severe mental health needs is not available; but all refuge organisations will offer support and information, and will assist women who have been abused in accessing appropriate service provision.

Mental health professionals need to be particularly aware of confidentiality and safety if they are considering involving partners in discussions over treatment. This is of particular concern if a woman is admitted to hospital as a result of being sectioned under the Mental Health Act; or if her partner is caring for her children while she is in residential treatment. Where a woman's "nearest relative" is identified as her abuser, consideration should be given to replacing him on the basis that he may not be acting in her or her children's best interests.

Confidentiality needs to be balanced with safe information-sharing. Organisations should develop information-sharing protocols for use when referring clients to other services, such as refuge organisations or other domestic violence services(xi).

Women clients should be offered the choice of a female key worker, CPN, psychiatrist or counsellor, if at all possible. Women-only wards should be offered to all women who are admitted to hospital, and women-only day-care services are also desirable.

Child protection policies and procedures should be fully explained to clients, to enable their fears (for example, that their children might be taken away) to be addressed. When child protection concerns are raised, adequate support should be given to women to enable children to stay with their mothers whenever possible. Those investigating child protection concerns should take care to avoid exacerbating the domestic violence.

When women have to leave home because of domestic violence, they should be able to transfer easily and quickly to relevant treatment in their new area.

Posters, leaflets and other information about domestic violence services should be displayed within all healthcare settings.

Mental health services should develop partnership working with other organisations, including domestic violence organisations. Representatives should attend local domestic violence forums, Crime and Disorder Reduction Partnerships, and other appropriate inter-agency organisations

Service users should be involved in planning and development of services.

Above all, the ongoing safety of women and children must be paramount.

These Principles of Good Practice are a product of the Women's Aid Mental Health, Substance Misuse and Domestic Violence Project, a three year initiative funded by the Department of Health. The first part of this project was a Survey to gather information on existing services. The Report of that Survey, Struggle to survive, is available from Women's Aid, price £10 (£8-50 for Women's Aid members).

In developing these Principles of Good Practice, I have greatly benefited from comments made on earlier drafts by a number of people, including Dr. Cathy Humphreys (University of Warwick), Michelle Newcomb from the Stella Project, and Jane Lewis, Nottingham City Council, as well as from others within Women's Aid.

1. A woman's mental health diagnosis may be used against her in civil or criminal proceedings, if, for example, she tries to obtain legal protection from her abuser, gain residence of her children, or give evidence if her partner is prosecuted for assault.2. We acknowledge that a small minority of domestic violence perpetrators may - because of severe mental illness, dissociative disorder, or mental incapacity - not be held fully responsible in law for their abusive behaviour; nonetheless it is important to acknowledge that their actions (rather than those of the victim) led to the resultant outcome.3. It is particularly crucial to take seriously any allegations of abuse by those who are most vulnerable and most likely to be disbelieved; for example, women with learning disabilities or who suffer from psychotic disorders. In only a small minority of such cases will allegations be completely misfounded.4. Some organisations will have Adult Protection procedures or Vulnerable Adult policies, based on the Department of Health's No secrets guidance (2001). These policies are complementary to, but not a substitute for, specific domestic violence policies and procedures.5. This could be implemented in conjunction with the recommendation that Primary Care Trusts and Mental Health Trusts should appoint a senior lead to drive the implementation of the Women's Mental Health Strategy within their trusts. See Department of Health (2003) Mainstreaming Gender and Women's Mental Health: Implementation Guidance, p.16.6. See Further Information at the end of this Guidance: perpetrators should only be referred to programmes which comply with Respect minimum standards.7. See Further Information at the end of this Guidance.

References: (i) Findings from the British Crime Survey self-completion module on interpersonal violence show that whereas 45% women and 26% men had experienced at least one incident of inter-personal violence in their lifetimes, women are much more likely than men to be the victim of multiple incidents of abuse, and of sexual violence, and are more likely to be injured as a result. Walby, Sylvia and Allen, Jonathan (2004) Domestic violence, sexual assault and stalking: Findings from the British Crime Survey (London: Home Office Research, Development and Statistics Directorate.) In this Guidance we will for convenience refer to the victim/survivor as female and the perpetrator as male. However, we expect the same principles to apply regardless of the gender of either party.(ii) See responses to Women's Aid survey, documented in Barron, J. (2004) Struggle to survive: Challenges for delivering services on mental health, substance misuse and domestic violence (Bristol: Women's Aid Federation of England) p.26; see also Department of Health (2003) Mainstreaming Gender and Women's Mental health: Implementation Guidance (London: Department of Health), p.47. (iii) Bowstead, Janet (2000) Mental health and domestic violence: Audit 1999 (Greenwich Multi-agency Domestic Violence Forum Mental Health Working Group); ReSisters (2002) Women speak out (Leeds: ReSisters); Department of Health (2003) op.cit. (iv)Astbury, J. (1999) Gender and Mental Health (Paper prepared under the Global Health Equity Initiative Project based at the Harvard Centre for Population and Development Studies); O'Keane, V. (2000) "Unipolar depression in women" in Steiner. M. et al. (2000) Mood Disorders in Women (London: Martin Dunitz, Ltd.); Humphreys, Cathy (2003) Mental Health and Domestic Violence: A research overview Paper presented at the "Making Research Count" Seminar on Domestic Violence and Mental Health, Coventry, 2003; Humphreys, Cathy and Thiara, Ravi (2003) "Mental Health and Domestic Violence: 'I call it symptoms of abuse'", British Journal of Social Work 33, pp.209-226; Vidgeon, N. (2003) Are support services failing victims of domestic violence? Unpublished Master's Thesis, Anglia Polytechnic University, Cambridge.(v) Golding, J. M. (1999) "Intimate partner violence as a risk factor for mental disorders: A meta-analysis" Journal of Family Violence Vol.14, No.2; Fikree, F.F. and Bhatti, L.I. (1999) "Domestic violence and health of Pakistani women" International Journal of Gynaecology and Obstetrics 65, pp.195-201; cited in Charles, N., Griffiths, L. and Morgan, J. (2003) The mental health needs of women who have experienced domestic abuse (Swansea: Neath Women's Aid).(vi) Stark and Flitcraft (1996) Women at risk: Domestic Violence and Women's Health (London: Sage); Mullender, Audrey (1996) Rethinking domestic violence: The Social Work and Probation response (London: Routledge).(vii) Chantler, K, et al. (2001) Attempted suicide and self-harm: South Asian women (Manchester: Women's Studies Research Centre, Manchester Metropolitan University); Newham Asian Women's Project: (1998) Young Asian Women and Self-harm: A mental health needs assessment of young Asian women in East London (London: Newham Inner City Multifund and NAWP).(viii) Phillips, Kelley (2000) "Sociogeopolitical issues" in Steiner et al. op.cit.; see also Department of Health (2003) ibid.; Department of Health (2002) Secure Futures for Women: making a difference (London: Department of Health).(ix) Kolbo, J.R., Blakeley, E.H., and Engelman, D. (1996) "Children who witness domestic violence: A review of the empirical literature" Journal of Interpersonal Violence Vol.11, No.2, p.281; Morley, R. and Mullender, A. (1994) "Domestic violence and children: what we know from research" in Mullender, A. and Morley, R. Children living with domestic violence; Putting men's abuse of women on the childcare agenda (London: Whiting and Birch Ltd.); Hester, M., Pearson, C., and Harwin, N. (2000) Making an impact: Children and domestic violence: A reader (London: Jessica Kingsley).(x) See for example the Social Exclusion Unit Report (2004) Mental Health and Social Exclusion (London: Office of the Deputy Prime Minister).(xi) See Douglas, Nicola, Lilley, Sarah-Jane, Kooper, Liz, and Diamond, Alana (2004) Safety and justice: Sharing personal information in the context of domestic violence - An overview (London: Home Office Development and Practice Report 30). This is a useful guide to the issues.